Patient handout

Resistant hypertension (≥3 meds at max + diuretic)

PRODUCTION

1. Your condition

This handout is for resistant hypertension (≥3 meds at max + diuretic). Your care team identified this based on: resistant htn — referred from primary htn engine (acc/aha 2017; carey aha 2018).

Other reasons your team may use this plan: office bp above target on ≥3 antihypertensives at max dose (acc/aha 2017; esc/esh 2023); bp controlled on ≥4 antihypertensives (acc/aha 2017; esc/esh 2023); positive secondary htn screen (carey aha 2018).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
chlorthalidone	12.5 mg	PO	once daily	Thiazide-like > thiazide — longer t1/2, more potent; preferred (ACC/AHA 2017; ALLHAT)
indapamide	1.25–2.5 mg	PO	once daily	Alternative thiazide-like; Beckett Lancet 2008 HYVET evidence in elderly
furosemide	20–40 mg	PO	BID	Crossover to loop when eGFR <30 — thiazide-like loses efficacy (ACC/AHA 2017)
lisinopril	10 mg	PO	once daily	RAS blockade Class I (ACC/AHA 2017; ESC/ESH 2023)
losartan	50 mg	PO	once daily	RAS blockade Class I; switch from ACEi for cough/angioedema (ACC/AHA 2017)
amlodipine	5 mg	PO	once daily	CCB backbone — long-acting (ACC/AHA 2017; ALLHAT)

Plan: Resistant HTN backbone — confirm 3-drug max-dose regimen (ACEi/ARB + CCB + thiazide-like diuretic)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — At goal — home BP <130/80 average

If you have:

7-day average home BP <130/80 (ACC/AHA 2017)
No headache, vision change, chest pain, or shortness of breath (ACC/AHA 2017)

Do this:

Take all BP meds exactly as prescribed every day at the same time (ACC/AHA 2017)
Continue DASH-style diet; <2 g sodium/day (ACC/AHA 2017)
Continue exercise plan (ACC/AHA 2017)
Daily home BP at same time, after voiding, both arms initially (ACC/AHA 2017)
Bring BP log to every clinic visit (ACC/AHA 2017)

YELLOW — Caution — home BP 140–159 / 90–99 OR symptoms

If you have:

Several home readings >=140/90 over 3-5 days (ACC/AHA 2017)
New mild headache, dizziness, leg swelling (ACC/AHA 2017)
New irregular pulse / palpitations (ACC/AHA 2017)
Missed doses recently (ACC/AHA 2017)

Do this:

Recheck BP technique cuff size, arm at heart level, 5 min rest, no caffeine/exercise 30 min prior (ACC/AHA 2017)
Confirm you took all medications today (ACC/AHA 2017)
Check for OTC meds that raise BP ibuprofen/naproxen, decongestants, herbal stimulants and stop if possible (ACC/AHA 2017; Carey AHA 2018)
Hold added salt; track sodium for 48 h (ACC/AHA 2017)
Call HTN clinic / PCP within 24-48 h (ACC/AHA 2017)

Call your provider if:

Home BP persists >=140/90 despite above (ACC/AHA 2017)
Any new symptoms headache, vision change, chest pain, shortness of breath (ACC/AHA 2017)

RED — Medical alert — BP ≥180/120 OR severe symptoms

If you have:

Home BP >=180/120 confirmed by repeat reading 5 minutes later (ACC/AHA 2017)
Severe headache, blurred vision, chest pain, shortness of breath, weakness or numbness on one side, severe nosebleed, or confusion (ACC/AHA 2017)

Do this:

Call 911 / emergency services immediately (ACC/AHA 2017)
Sit down, stay calm, do not drive yourself (ACC/AHA 2017)
Bring medication list and BP log (ACC/AHA 2017)
Do not take an extra dose of BP medication unless instructed by your provider (ACC/AHA 2017)

Call your provider if:

Any red zone reading or symptom — go to ED now, do not wait (ACC/AHA 2017)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

BP ≥180/120 + neuro deficit, CP, ACS, pulm edema, AKI, vision change, or eclampsia (ACC/AHA 2017)(life-threatening)
BP ≥180/120 with no end-organ damage (ACC/AHA 2017)
K ≥5.5 on spironolactone / eplerenone / finerenone (Williams Lancet 2015 PATHWAY-2)
Cr rise >0.3 mg/dL or 50% on ACEi / ARB / diuretic / MRA (ACC/AHA 2017)
Plasma free metanephrines ≥3x ULN or 24-h urine fractionated metanephrines elevated (Carey AHA 2018)

5. Follow-up

q3 mo until controlled, then q6 mo; ASCVD prevention bundle; reassess adherence at every visit (ACC/AHA 2017; ESC/ESH 2023)

6. Sources

Guideline: 2025 ACC/AHA HTN Guideline + 2024 ESC/ESH HTN Guidelines + KDIGO 2021 BP in CKD + PATHWAY-2 + SPYRAL HTN-ON MED + RADIANCE-HTN